Modified distal aortopulmonary fistula repair

The main-pulmonary septal defect, also called aortic-pulmonary spasm, aortic-pulmonary window, is an extremely rare cardiovascular malformation, accounting for 0.3% to 1% of congenital heart disease. The disease is due to the incomplete process of separating the arterial trunk from the aorta and the pulmonary artery, leaving a defect between the ascending aorta and the pulmonary artery to form this septal defect. Such defects can occur anywhere between the ascending aorta and the pulmonary artery. Mori et al. divided the primary-pulmonary septal defect into three types in 1978. Type I: proximal-pulmonary septal defect, equivalent to the position above the semilunar annulus; type II: distal-to-pulmonary septal defect, distal to the ascending aorta and pulmonary artery; type III: complete defect of the main-pulmonary artery. In addition, there is a type of aortic-pulmonary septal defect at the level of the right pulmonary artery opening that is less common in clinical reports. Such defects generally open to the posterior wall of the ascending aorta. The size of the defect varies from a few millimeters to 6 cm, generally about 2 cm, and the defect is elliptical. Often with patent ductus arteriosus, atrial septal defect, ventricular septal defect, coronary artery abnormalities, right aortic arch, tetralogy of Fallot and other cardiovascular malformations. The main-pulmonary septal defect is similar to patent ductus arteriosus, but the blood is left-to-right shunt from the ascending aorta through the defect to the pulmonary trunk. Since the defect is often larger than the patent ductus arteriosus, the blood flow is large and the pulmonary blood flow is high. Significantly increased, the development of dynamic pulmonary hypertension, such as early surgery, pulmonary intima thickening, middle muscle fiber hyperplasia, small lumen and other lesions, the formation of resistance pulmonary hypertension. In cases where the right pulmonary artery originates from the aortic opening, left lung hypertension may occur. The cause of contralateral pulmonary hypertension is unclear and is believed to be related to the reflex mechanism. Clinically similar to patent ductus arteriosus, but the symptoms appear earlier, heavier, and develop faster. The diagnosis can be determined by two-dimensional echocardiography, cardiac catheterization, and retrograde aortic angiography. The modified surgical procedure is suitable for the repair of a septal defect at the distal end of the main-pulmonary artery with an infant whose right pulmonary artery originates from the ascending aorta. In 1991, Kitagawa et al. reported this method and received good results in clinical applications. Treatment of diseases: primary-pulmonary septal defect Indication The main-pulmonary septal defect is located distally and the right pulmonary artery originates from the ascending aorta. Contraindications Pulmonary vascular resistance was significantly increased, with irreversible pulmonary vascular obstructive disease, clinical occurrence of cyanosis, right-to-left shunt is the main contraindication for corrective surgery. Preoperative preparation In addition to the routine preparation of general cardiopulmonary bypass surgery before surgery, pay special attention to the following points: 1. Preoperative diagnosis of coronary angiography by two-dimensional echocardiography, especially attention to patent ductus arteriosus, high ventricular septal defect with aortic regurgitation, aortic sinus aneurysm rupture and coronary venous venous Identification. And pay attention to the merger of other cardiovascular malformations. 2. Preoperative blood oxygen saturation measurement and cardiac catheterization were used to evaluate hemodynamic status, including pulmonary vascular resistance. 3. Patients with severe congestive heart failure and pulmonary infection should undergo medical treatment to control heart failure and infection to improve surgical safety. Surgical procedure 1. The midline incision of the chest shows that the right pulmonary artery starts from the right posterior side of the ascending aorta, and the right side of the distal end of the main pulmonary artery is connected to the left posterior aspect of the ascending aorta in the same plane of the right pulmonary artery. 2. According to the routine placement of the ascending aorta and superior inferior vena cava intubation, moderate hypothermic cardiopulmonary perfusion, block the ascending aorta. 3. When the coronary artery is cold-irrigated, the left and right pulmonary artery should be temporarily blocked to ensure the coronary artery perfusion. 4. The ascending aorta was incised laterally at the proximal end of the right pulmonary artery and proximal to the ascending aortic obstruction forceps. It can be seen that there is an opening on the left and right sides of the posterior wall, which is in communication with the main pulmonary artery and the right pulmonary artery, that is, the main-pulmonary artery septal defect and the right pulmonary artery opening. The continuation between the two openings is the posterior wall of the ascending aorta. 5. The aortic incision was extended to both sides, and an arc-shaped incision was made to the posterior superior and posterior, respectively. The ascending aorta was dissected, and the posterior wall of the ascending aorta was cut to form a right pulmonary artery with a proximal anterior wall defect. 6. Cut a pericardial piece and suture continuously with 5-0 non-invasive suture to repair the right pulmonary artery incision and reconstruct the right pulmonary artery channel. 7. Finally, the 5° suture was used to suture the ascending aorta continuously to reconstruct the ascending aorta. Infants and young children can be sutured with non-invasive absorbable sutures when repairing the right pulmonary artery incision and anastomosis of the ascending aorta, without affecting the growth and development of infants and young children.